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Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is COVID-19 vaccination linked to the occurrence of myocarditis?

Findings  In this study of 7 patients with acute myocarditis, 4 occurred within 5 days of COVID-19 vaccination between February 1 and April 30, 2021. All 4 patients had received the second dose of a messenger RNA (mRNA) vaccine, presented with severe chest pain, had biomarker evidence of myocardial injury, were hospitalized, and had cardiac magnetic resonance imaging findings typical of myocarditis.

Meaning  Although causality cannot be established, the findings raise the possibility of an association between mRNA COVID-19 vaccination and acute myocarditis.

Abstract

Importance  Vaccine-associated myocarditis is an unusual entity that has been described for the smallpox vaccine, but only anecdotal case reports have been described for other vaccines. Whether COVID-19 vaccination may be linked to the occurrence of myocarditis is unknown.

Objective  To describe a group of 7 patients with acute myocarditis over 3 months, 4 of whom had recent messenger RNA (mRNA) COVID-19 vaccination.

Design, Setting, and Participants  All patients referred for cardiovascular magnetic resonance imaging at Duke University Medical Center were asked to participate in a prospective outcomes registry. Two searches of the registry database were performed: first, to identify patients with acute myocarditis for the 3-month period between February 1 and April 30 for 2017 through 2021, and second, to identify all patients with possible vaccine-associated myocarditis for the past 20 years. Once patients with possible vaccine-associated myocarditis were identified, data available in the registry were supplemented by additional data collection from the electronic health record and a telephone interview.

Exposures  mRNA COVID-19 vaccine.

Main Outcomes and Measures  Occurrence of acute myocarditis by cardiovascular magnetic resonance imaging.

Results  In the 3-month period between February 1 and April 30, 2021, 7 patients with acute myocarditis were identified, of which 4 occurred within 5 days of COVID-19 vaccination. Three were younger male individuals (age, 23-36 years) and 1 was a 70-year-old female individual. All 4 had received the second dose of an mRNA vaccine (2 received mRNA-1273 [Moderna], and 2 received BNT162b2 [Pfizer]). All presented with severe chest pain, had biomarker evidence of myocardial injury, and were hospitalized. Coincident testing for COVID-19 and respiratory viruses provided no alternative explanation. Cardiac magnetic resonance imaging findings were typical for myocarditis, including regional dysfunction, late gadolinium enhancement, and elevated native T1 and T2.

Conclusions and Relevance  In this study, magnetic resonance imaging findings were found to be consistent with acute myocarditis in 7 patients; 4 of whom had preceding COVID-19 vaccination. Further investigation is needed to determine associations of COVID-19 vaccination and myocarditis.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Raymond J. Kim, MD, Duke Cardiovascular Magnetic Resonance Center, DUMC-3934, Durham, NC 27710 (raymond.kim@duke.edu).

Accepted for Publication: May 28, 2021.

Published Online: June 29, 2021. doi:10.1001/jamacardio.2021.2828

Author Contributions: Drs H. W. Kim and R. J. Kim had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: H. W. Kim, Azevedo, Campbell, R. J. Kim.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: H. W. Kim, Jenista, Wendell, Campbell, Darty, Parker, R. J. Kim.

Critical revision of the manuscript for important intellectual content: H. W. Kim, Jenista, Azevedo, Campbell.

Administrative, technical, or material support: H. W. Kim, Jenista, Wendell, Azevedo, Campbell, Darty.

Supervision: H. W. Kim, R. J. Kim.

Conflict of Interest Disclosures: Dr Campbell reported personal fees from Longeeveron outside the submitted work. Dr R. J. Kim reported holding equity interest in Heart Imaging Technologies and grants from Siemens outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank all 4 patients for granting permission to publish this information.

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